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In 2010 we sent him our first pulse oximeter. Lifebox wasn’t even Lifebox back then – it was the Global Pulse Oximetry Project, fresh from a worldwide tendering process led by WHO and the WFSA for an ideal monitor to thrive in low-resource settings.

We were perched on a desk in a third floor room at the AAGBI in London, figuring out what to do next.

Sure, we had our oximeter – robust, intuitive, with an education package, rechargeable batteries and a bright yellow glow – but no clear ordering system, no troubleshooting guide – and no proven plan for delivery.

If we had a hope of closing even one Operating Room’s pulse oximetry gap (let alone the gap in 77,000), we needed to design and test our systems beyond reproach.

Ray Towey understood.

A British anaesthetist, he’d been working in Africa for more than 20 years – first in Tanzania and then in northern Uganda.

He took one of the first modern hospital pulse oximeters in his rucksack to St Mary’s Lacor in Gulu, a large church hospital, back in the 1980’s. It cost about £2000.

“I started anaesthesia in 1968 – I’m old enough to remember giving it before oximetry. And in poor countries, people were dying from hypoxia before we noticed, particularly people with dark skin. So when the oximeter came, we knew we couldn’t do without it. First we carried one, then another,” he told us.

“People die when you don’t have one in the operating room,” he explained, sitting forward on the couch during a visit to the AAGBI. “And we give inappropriate oxygen therapy when we don’t have the oximeter in the neonatal unit.”

People die, that is, from conditions that would be treated and discharged as a matter of routine in Western Europe. They die from treatments that are supposed to save them, because the safety mechanisms aren’t in place.

As a medical professional – seeing this, knowing this – how do you move between worlds and not break down?

Ray Towey is an activist.

“I’ve been very active in the peace movement in the U.K. I was in jail in the 1980’s, active in the CND doing protest and resistance – the obscenity of nuclear weapons, what a waste of life and energy.

I never learned to live with the indifference of my culture. But I live with that as – a dissident. So as a dissident I’m doing my best to make the changes here. And as a healthworker.”

He took action at St Mary’s. Working with colleagues in the OR, in the ICU. Today the hospital hasn’t had a death on the operating room table in current students’ memory. They’re saving patients who would never be saved without their teamwork and systems. The challenge remains to reduce complications in the post-operative period. But that knowledge, that teamwork – that makes it worthwhile.

Ray Towey is a humane man.

“When I lose a patient it hurts very much. And sometimes when you lose a patient in some particular situation – especially when they’re young – it hurts a lot.

I walk through the waiting room of the intensive care unit in Gulu about five times a day. And because I know a certain percentage are going to die, sometimes I can’t look them in the eye.”

it didn’t arrive. Not the first week, or the second. Or the first month, or the second.

Thanks to Ray we had our answer and our system. Since 2010 all Lifebox oximeters have been shipped by courier service. It’s a bit more expensive, but it’s the only way to guarantee that our equipment arrives in the hands of the people who use it, and on the fingers of the patients who need it, as soon as possible.

We sent a new shipment to Ray.

“The concept of giving an anaesthetic without an oximeter is like not wearing shoes on the streets of central London,” he explained. “It’s just inconceivable that anyone would want to do that.

With more than 8,300 oximeters distributed to 90 countries around the world since, we haven’t lost a package.

In the spring of 2011 we got an email from Ray, and a photo.

“We used one of the oximeters on a sick neonate which is a big test. It did a good job for us. I think its got excellent software and was a good choice.”

P.S. Not wishing to do injustice to the postal service or the value of every donation – believe it or not, the first shipment arrived! Three months later, surfacing in the Post Office in Kampala. But we still use a courier service – 77,000 operating rooms around the world have already waited long enough.

“Almost all the hospitals have a graveyard,” says Dr Harry Aigeeleng, an anaesthetist in Papua New Gunea, when he sat down with us at the WCA last month.

Lifebox Trustee Angela Enright and Dr Aigeeleng are old friends - they like to catch up and pose for photos

This isn’t quite as morbid as it sounds, but it’s certainly depressing. Harry is talking about equipment graveyards – warehouses, cupboards, row after row of medical devices that are theoretically useful but practically useless in the context of the environment they’ve been sent to.

“There’s no maintenance, so things break down,” Harry explains, of the many devices that could be fully functional if it weren’t for the impossibility of replacing basic spare parts, or calling out a service engineer to a rural hospital on a regular – or even emergency – basis.

All this potential...

Even worse than those items made redundant in action are those that never had a chance to serve.

“There are those devices that are donates – but some part is missing, or they didn’t come with an instruction booklet – or the booklet is in a foreign language…” he shakes his head.

...that might as well be empty space.

Look at the pictures, and it’s shocking to see what these graveyards equate to in wasted value and opportunity – and what a disconnect in communication they memorialize.

This is Jimmy, a nurse anaesthetist in Uganda.

He was photographed by Dr Louise Finch, a member of our UK faculty running the Lifebox training programme in Mbarara, Uganda last summer. From September, Louise spent three months traveling the country to follow up on the 80 donated oximeters (an adventure that deserves many and more blog posts of its own, so stay tuned!) and met up with him at his hospital.

He’s standing proudly next to an anaesthesia machine, which he keeps in pristine condition despite the ubiquitous red Ugandan dust. It makes a very useful table for his Lifebox oximeter, but not much more. All of the dials are in Italian.

We conceived the Lifebox pulse oximeter for a long life three feet above ground (about the height of an operating table). It doesn’t need servicing or recalibrating; it is compatible with generic probes, so it’s much more likely that you can find a replacement for it; and it runs on rechargeable batteries so that you can continue to use it if the power cuts out during an operation.

There are a lot of organizations that aim to keep equipment mortality low. One part of Global Partners in Anesthesia and Surgery (GPAS)’s work focuses on improving service and education infrastructure. Engineering World Health sends biomedical engineers to low-resource countries to teach and train locally. Powerfree Education Technology (PET) aims to develop fit-for-purpose medical technologies to improve maternal healthcare. And our own WFSA offers guidelines and assistance to hospitals, so that they can question manufacturers directly about the suitability of equipment.

“If people have monitors, they work them till they are dead,” says Harry. They don’t need expensive and misplaced wallflowers – they need equipment that will work to last, as long and as hard as they do.

Road traffic accidents in Uganda are frequent and brutal. Two years ago, the anaesthesia community at Mulago Regional Referral Hospital, the largest in the country, lost several of its own when a minibus carrying anaesthetic SHOs to a funeral was swiped off the side of the road.

Treatable injuries became fatal ones: the same infuriating story we heard many accounts of over the next few weeks. No drugs; no staff; no electricity; no efficient transport.

“In a country that has only 0.6 anaesthetic providers per 100,000 population (unlike the UK which has 20) this is a huge blow,” wrote Dr Sarah Hodges, Head of Department of Anaesthesia at the CoRSU Rehabilitation Hospital in Kisubi.

The World Health Organziation, which launched a Decade of Action for Road Safety in May, estimates that road traffic accidents will be the fifth leading cause of death by 2030.

As we crammed into a mutatu, cab, for the 300km journey down to Mbarara, suitcases strapped to the roof, squaring up to oncoming traffic and picking up speed along torn up and dusty roads, it was easy to believe.

Improvements in infrastructure over the last few years have certainly made cross-country journeys easier, but thunderstorms on the Monday before our training course began had swamped potholes and slowed travel. The participants, stationed in hospitals and health centres as far north as Abel, by the border with South Sudan and west, across the Rwenzori Mountains, travelled hundreds of kilometres to get to Mbarara in the south.

Many who had left their posts before dawn were still arriving, wet and tired, the following morning.

This is Khasitsi Khalayi – a 40 year old anaesthetic officer at a Health Center 4 in the Mbale district, in Eastern Uganda.

“Since here are so many patients – sometimes you have shortages, sometimes you are alone – of drugs, of materials, staff. Sometimes because of these shortages you are overworked, and patients are many. You encounter some problems,” she explained.

Khasitsi left her home the day before, traveling by bus to Kampala where she boarded another bus to Mbarara, arriving at 2am. She got on a boda boda, a motorcycle, and met Dr Stephen Ttendo at the University.